DEPARTMENT OF PUBLIC SAFETY / P.O. BOX 1628 / SANTA FE

DEPARTMENT OF PUBLIC SAFETY / P.O. BOX 1628 / SANTA FE, NM 87504-1628

ATTN: RECORDS $15.00 PER RECORD CHECK

AUTHORIZATION FOR RELEASE OF INFORMATION

I,___________________________________________________________________________________

NAME (MUST BE PRINTED-LEGIBLY)

(SSN#)

(DOB)

Alias' Name:___________________________ SSN:____________________DOB:_________________________

Name:___________________________ SSN:____________________ DOB:_________________________

____________________________________________________________________________________

NAME OF AGENCY OR PERSON RECEIVING ARREST RECORD

ADDRESS:__________________________________________________________________________

AS AN AUTHORIZED AGENT FOR ME FOR THE PURPOSE OF INSPECTING (AND /OR

OBTAINING COPIES OF) ANY NEW MEXICO ARREST FINGERPRINT CARD SUPPORTED

ARREST RECORD INFORMATION MAINTAINED BY THE DEPARTMENT OF PUBLIC SAFETY,

INCLUDING INFORMATION CONCERNING FELONY OR MISDEMEANOR ARRESTS AND

INFORMATION OBTAINED FROM RELEVANT FINGERPRINT DATABASES.

TO THE CUSTODIAN OF THE RECORDS IN QUESTION, I HEREBY DIRECT YOU TO RELEASE

SUCH INFORMATION TO THE AUTHORIZED AGENT AS DESCRIBED ABOVE.

I HEREBY RELEASE THE CUSTODIAN OR CUSTODIANS OF SUCH RECORDS AND THE

DEPARTMENT OF PUBLIC SAFETY, INCLUDING ANY OF THEIR AGENTS, EMPLOYEES, OR

REPRESENTATIVES IN ANY CAPACITY, FROM ANY AND ALL CLAIMS OF LIABILITY OR

DAMAGE OF WHATEVER KIND OR NATURE, WHICH AT ANY TIME COULD RESULT TO ME,

MY HEIRS, ASSIGNS, ASSOCIATES, PERSONAL REPRESENTATIVE OR REPRESENTATIVES

OF ANY NATURE BECAUSE OF COMPLIANCE BY SAID CUSTODIAN OR CUSTODIANS WITH

THIS "AUTHORIZATION FOR RELEASE OF INFORMATION" AND MY REQUEST CONTAINED

HEREIN FOR THIS RELEASE OR BECAUSE OF ANY USE OF THESE RECORDS. THIS

RELEASE IS BINDING, NOW AND IN THE FUTURE AND IS VALID FOR A PERIOD OF UP TO

120 DAYS FROM THE DATE SIGNED, ON MY HEIRS, ASSIGNS, ASSOCIATES, PERSONAL

REPRESENTATIVE OR REPRESENTATIVES OF ANY NATURE.

APPLICANT SIGNATURE:_________________________________

DATE:____________________________________

SIGNED AND SWORN TO BEFORE ME ON THIS _______ Day Of________________20______

State of_________________ County of_______________

(SEAL)

__________________________________

(SIGNATURE OF NOTARY PUBLIC)

MY COMMISSION EXPIRES:____________________

For Department of Public Safety Use Only